Module 2: Wounds Flashcards
3 types of wound healing
primary, secondary, tertiary intention
primary intention
surgical wounds closed with sutures/staples
secondary intention
wound left open and heals through scar formation
tertiary intention
delayed primary closure, left open for time and later closed
stages of wound healing
hemostasis, inflammation, proliferation, remodelling
factors that affect wound healing
age, edema, wrong dressing used for needs of the wound, nutritional deficit, impaired oxygen, accumulation of drainage, medications, immunosuppression, stressors, infections
documentation of wounds
pain, size, bed, exudate (type, amount), odour, peri-wound care
describing wound location
anterior & posterior, lateral & medical, proximal & distal
measurement of a wound
length (longest measurement), width (widest measurement), depth (deepest part)
describing a wound bed
r/t type of tissue present and expressed as an estimate % for each type of tissue observed
types of tissues
granulation, eschar, slough, underlying structures (bone, tendon)
granulation
healthy tissue, firm, red, moist, pebbled
eschar
dry, black, brown, dead tissue
slough
dry or wet, loose or firmly attached, yellow/brown - dead tissue
types of wound exudate
serous, sanguineous, serosanguineous, purulent
serous fluid
clear, thin, watery
sanguineous
bloody drainage
serosanguineous
clear with some blood
purulent
thick, yellow, green, tan, or brown
amount of wound exudate
non, scant, small, moderate, copious
wound edge
attached or detached
attached wound edge
flush with wound bed
detached wound edge
not flush with wound bed - “cliff” sits above wound bed
peri-wound skin
skin around wound
types of peri-wound skin
erythema, maceration, induration, rash
maceration
looks white - too much moisture
induration
skin feels firm
pressure injuries
located over bony prominences where prolonged pressure occurs
stage 1 pressure injuries
non-blanchable erythema of intact skin
stage 2 pressure injury
partial-thickness skin loss, exposed dermis
stage 3 pressure injury
full-thickness skin loss
stage 4 pressure injury
full-thickness skin and tissue loss
unstageable pressure injury
obscured full-thickness skin and tissue loss
deep tissue pressure injury
intact skin, dark red/purple bruise, firm to touch
risk factors for impaired skin integrity
immobility, impaired sensory perception or cognition, decreased tissue perfusion, altered nutritional status, friction and shear, increase moisture
arterial ulcers
r/t tissue ischemia, risk of infection
location of arterial ulcers
lower legs, toes
description of arterial ulcers
small, circular, deep & painful with minimal drainage
venous ulcers
r/t impaired venous blood return
location of venous ulces
lower leg, ankle
description of venous ulcers
skin cool to touch, pale, shiny & may see hemosiderin straining and edema
management of arterial and venous ulcers
antibiotics (if infection present), compression therapy (if not contradicted), debridement, wound dressings, hyperbaric oxygenation, negative pressure wound therapy, improving physical mobility, nutrition
cause of diabetic ulcers
peripheral neuropathy, changes to foot structure seen in neuropathy, trauma/pressure
location of diabetic ulcers
plantar foot structure
management of diabetic ulcers
pt teaching, assess feet daily, how to clean feet (wash, dry, avoid moisture in between toes), wear closed-toe shoes that fit properly, how to trim toenails, reduce risk factors (smoking)
